The UK's assisted dying debate
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Save now during Bray Friday at Bray & Scarf, where it doesn't cost more to get more. Hello, I'm Katya Adler from the BBC World Service. This is The Global Story. Parliament in the United Kingdom is preparing to vote on whether terminally ill adults in England and Wales can get help legally to end their lives.

Fraught with ethical dilemmas, so-called assisted dying has long proved a divisive topic in the UK. It's still very divisive now. The dramatic social change that new legislation could bring about is being compared to the legalisation of abortion at the time, the abolition of the death penalty and the introduction of same-sex marriage.

Around the world, it's already legal in some form in a growing number of nations. What are the experiences there? With me today is Dominic Hughes, the BBC's global health correspondent. Hello, Dominic. Hi there, Katja. So this discussion of assisted dying, it's become massive in the UK at the moment, hasn't it? I mean, it's really, it's a huge debate politically, but also socially.

Yeah, it's almost like one of the last big liberal debates to be had in the UK. We've seen big discussions over the last 40 years about things like equalities legislation, the death penalty, abortion, divorce, gay marriage. All of those things have been legislated on and in the end resolved, in fact liberalised, and it feels as if

That is the way the tide of history is running at the moment. And this is perhaps the last of those big liberal issues to be discussed in the UK. And it really has focused people's attention on a very, very difficult and divisive issue.

Yeah, absolutely. And how do you approach it as a journalist? Because it's such an emotive issue. It's very explosive topics. How do you navigate that as you cover a story like this for the BBC? I think you just need to sort of get down to the basics, really, about exactly what is this legislation trying to achieve and what are the sort of key issues that it's trying to resolve. It's interesting that both sides of this argument disagree.

often talk about choice and autonomy. That's one reason why it's so fascinating. And, you know, it's such a painful issue for so many people. But it really gets to the core of who we are and how we live our lives and how we end our lives.

So we're going to go big in this, aren't we? We're going to talk about big ethical questions like that in the episode. But let's start with the micro before we get to the macro. What are we talking about here in the UK in terms of proposed legislation?

I'm going to go one step back because we're talking about what people often refer to as assisted dying. But even that language, right, is contested. So assisted dying generally refers to a person who's terminally ill, receiving lethal drugs from a medical practitioner, which they then take themselves. There's also this idea and the opponents of assisted dying often talk about assisted suicide.

That's a more laden term. That's intentionally helping another person to end their life, including someone who may not be terminally ill. And that could involve providing a lethal medication or helping them travel to another jurisdiction or another country where they choose to die. And then there's also euthanasia, which is the act of deliberately ending a person's life to relieve suffering in which a lethal drug is administered by

by a physician, by a doctor, and those patients may not be terminally ill. There are two types. There's voluntary euthanasia where a patient consents, non-voluntary where they can't consent because, for example, they might be in a coma. So all that language is in play. This thing that we're talking about this week in the UK Parliament is the first vote on this issue since 2015. It's called the Terminally Ill Adults End of Life Bill.

ill. And it would make it legal for anyone over the age of 18 who is terminally ill to be given assistance to end their own life. And it would apply only in England and Wales, so not Scotland, not Northern Ireland. The eligibility is actually fairly narrow. The bill itself says to allow adults aged 18 and over who have mental capacity, are terminally ill and are in the final six months of their life to request assistance from a doctor to end their life. But

There are quite a lot of other requirements. They've got to be resident in England and Wales and be registered with a general practitioner for at least 12 months. They must make two

two separate declarations which have to be witnessed and signed about their wish to die and two independent doctors have to be satisfied that the person is eligible and there's got to be seven days between those doctor's assessments and finally a High Court judge has got to hear from at least one of the doctors and can also question the dying person or anyone else who they consider to be appropriate and there's got to be a further 14 day cooling off period after the judge has made the ruling.

So, Dominic, that's a massive list of and then, and then, and then, and then. And that has led to the Member of Parliament who is sponsoring the bill or who's authored the bill to say these are the tightest provisions of assisted dying in the world if it goes through as she has suggested. Is that right? I mean, I think it is. Opponents say there are loopholes and they have worries, and I'm sure we'll get into that later.

But she says it's based on the experience of the many countries now around the world who have adopted this kind of legislation. It has to be done safely. It has to be done with the robust protections that the bill includes. But I think fundamentally, it's about the dying person and their rights. And what the bill very clearly says is...

The doctor has a duty to discuss all available options with the patient. And what I believe that will do is give us a much more holistic approach to end-of-life care in this country, which we just don't have at the moment. We're not speaking about the options that are available to people. That will include palliative care. It will include psychological support. It will be a very thorough and robust consultation and conversation.

It most closely mirrors legislation in Oregon in the United States, but more particularly perhaps the state of Victoria in Australia. And that legislation has been up and running. So the supporters of the bill say we've looked at what's happened there. We see the problems that may have occurred. We've addressed those. And they say that's why it's the most watertight type of legislation of its kind.

And we are going to have a look at international comparisons in a moment. But staying with the practical here, it is what's called a private members bill. So it is proposal for legislation coming from this one MP. So that means that the government, which is currently a Labour government, a centre-left government in the UK, isn't saying to its own members of parliament, you must vote one way or another.

Yeah, that's absolutely right. So MPs have been given what they call a free vote. That's not always the case with private members' bills, but it means that they can make their own decision rather than follow their party instructions. So it's up to the individual conscience, if you like, of every individual MP. And it's not clear at all at this stage...

how many MPs are going to vote to support the bill. Most of them haven't said publicly how they intend to vote. When they last looked at this issue in 2015, it was rejected. It was a different proposal, but it was rejected by 330 votes to 118. But this is a very different proposal. It's a very different parliament. It has a lot of first-time MPs in it. It's a very different sort of make-up of the parliament. And I

I think it is very, very difficult to see what's going to happen at the moment. Very difficult to predict, certainly. I think that's a really important point you make, Dominic, that it's a very different parliament. Because if we take our listeners back, we've only just had a general election in the United Kingdom. So that was over the summer. The Labour Party won that election and it has a very comfortable majority. So there are a lot of very brand new, shiny, fresh candidates.

Members of Parliament. I think often before we get to the debate for and against assisted dying, Dominic, I think it's worth sometimes putting ourselves in the position of these brand new shiny MPs who are literally learning the ropes of everything, just how Parliament works and all the rest of it. And this could be the most significant vote they face in their entire careers, something they're getting right at the beginning.

Yeah, it's interesting, isn't it? So how does that play out? That's one of the key issues we'll be watching on Friday. So for many of them, as you say, this will be the very first big vote like this that they've been asked to consider. Does that mean they adopt a more cautious, conservative, with a small C stance, sort of play it safe, if you like? Or because they're so new, many of them are younger voters,

Are they actually reflecting more what's going on in the UK, where there has for years now been solid support in opinion polls for this kind of legislation? So we've already touched on this, Dominic. Of course, assisted dying or euthanasia, this has been a debate in many countries all over the world. You mentioned Australia. You mentioned Oregon in the United States, that

This particular bill that UK MPs are voting on on Friday is linked to. But the Netherlands, very close by, I mean, that's a country that's practiced assisted dying for many, many years, decades actually. How does that compare to what's being proposed in the UK? So it's interesting, isn't it? More than 300 million people now live in countries which have legalized assisted dying.

And the pace at which that legislation has been introduced in different countries has really picked up since 2015. You mentioned the Netherlands. Well, along with Belgium, they both legalised assisted dying more than 20 years ago for patients experiencing what they described as unbearable suffering from an incurable illness. But that includes mental health issues. And since then, it's been extended to children.

"Assassins", someone cries from the public gallery as politicians pass a law removing all age limits for euthanasia. It makes Belgium the first country to allow terminally ill children old enough to speak to have the right to ask to die. They are the only European countries that allow children

to access assisted dying, they have to have parental support and both also allow euthanasia or physician-assisted dying. So that is an extremely liberal, with a small l, approach to this issue and

nowhere else in Europe or indeed nowhere else in the world really has such a liberal approach to it. I mean, it is absolutely fascinating because I think one of the big concerns that's expressed in the United Kingdom by critics of the bill, people who are concerned about it, say they worry about individuals coming under pressure to take the decision to end their lives and

by others around them. So it could be loved ones who are after an inheritance or people around them who are finding the burden too big of looking after somebody. The whole argument about coercion, which is what we're talking about, is one of the big questions that opponents of the legislation in the UK have raised. They worry about exactly that.

But supporters of the bill say we are for the first time making coercion a crime that would be punishable with a prison sentence. So there is that argument. If we look at Victoria in Australia, they have argued there that actually it's often the family's fault.

who are trying to talk people out of assisted dying. That's often where the conflict within families is coming from, is within those families where the rest of the family is saying to the person who's dying, stay with us, stay with us. Under the UK bill, a doctor could prepare the substance that an individual would take to end their lives, but that individual has to take it themselves.

How does that approach compare to other countries? Yeah, so that's one of the points of difference between different nations, different jurisdictions. Canada, Netherlands, Belgium allow clinical administration by a doctor of the substance, but the US states and Switzerland, for example, don't.

But in other instances, so for example, in Italy, in Germany, in Colombia, court rulings have ruled that doctors can't be prosecuted for assisting a terminally ill person to end their life. So Germany, for example, the Constitutional Court said in 2020 that people assisting a suicide couldn't be punished. But the Bundestag has so far failed to pass any legislation to rule on this. So they're sort of caught in a bit of a grey area.

Looking at international studies, terminally ill patients tend to take up the opportunity of assisted dying more if there is a doctor involved than if there isn't.

Yeah, it's really interesting. The proportion of deaths by assisted dying is higher in countries where the medication is administered by doctors rather than self-administered. So in the Netherlands, more than 5% of all deaths are assisted deaths. In Canada, it's nearly 4.5%. Australia, it's just 1.5%. And the USA, it's less than 0.5%.

If we look at Oregon, another jurisdiction that's seen as a model for what's being proposed for England and Wales, the most recent data shows that about one in three people who obtain the medication choose not to take them, often due to being in palliative care. And in Australia, it was about one in five. I think that is really fascinating, that people want to have the option. They want to have that safety net if they need it, but they don't always take it up.

What about assisted dying tourism? Because it's a thing, isn't it? If there are a limited amount of countries that have the option, there will be others who say, I want to go there if I want to choose to end my own life. Would the UK legislation allow that possibility?

Not as it's framed at the moment, no. In most of the countries and territories where they have this kind of legislation, you have to be resident or at least resident for 12 months at least to access these services. The most obvious exception to that is Switzerland, which was the first country in the world to create a right, what they call a right to die, when it made assisted suicide legal back in 1942.

And it's one of the few countries which allows foreigners access to help to die via organisations like Dignitas in Zurich. Now, more than 500 British people have died at Dignitas.

And that's just over the last two decades, including 40 people last year. And the lethal medication that they give at Dignitas has to be self-administered. Canada is one country where they have a federal right to assisted dying, but you have to be eligible for health services in the country. So you have to be living there.

Then Oregon in the United States, it's been legal in Oregon since 1997. But since March 2022, you no longer have to be a resident of the state to participate in what they call their Death with Dignity Act. So we've looked at what we mean by assisted dying, what exactly is being proposed in the UK and how it compares to laws in other countries.

Next, we're going to take a close look at the ethics of the debate. I'm Crassi Twig, and on the documentary, we zoom in on the backstory of the Syrian militant group that led a coalition of rebels to take control of Aleppo. Once an offshoot of al-Qaeda, HDS rebranded itself in its desire to be seen as a credible governing body.

To listen to this episode of The Global Jigsaw, where we look at the world through the lens of its media, search for the documentary wherever you get your BBC podcasts. This is The Global Story. We bring you one big international story in detail five days a week. Follow or subscribe wherever you listen.

With me is the BBC's global health correspondent, Dominic Hughes. Dominic, we're going to talk now about the ethics, the pros, the cons, the concerns. Historically, the strongest opposition to the idea has been the sanctity of life. I mean, that's often come from religious people, hasn't it? Yeah, I think that's a fair point. Religious communities have formed the backbone, I think, of the opposition movement.

to various efforts to introduce this legislation in the UK particularly. And for many people, the sanctity of human life is absolutely just a red line they are not willing to cross. But as we mentioned before, public opinion has shifted over the years and it now looks like it's solidly behind a change.

That maybe reflects that the UK has become, you know, a much more secular society. Those people who identify with a particularly organised religion has declined. And one interesting change, I think, has been the move in the medical establishment in the UK, going from a position of opposition a few years ago to one of neutrality now. And you'll find plenty of medics on both sides of the argument, those who support this kind of legislation, those who oppose it.

Dominic, do you think it echoes the debate around abortion, for example? And of course, these are very, very different circumstances, but about the terminology and attitude sometimes and individuals saying, I have a right over...

over my own body and I have a right to decide what I do with my body. These are the more, I suppose, secular arguments that we're hearing now. It's fascinating, isn't it? Because I think it comes down to this idea of a freedom to and a freedom from. And there are lots and lots of parallels, I think, with the debates over abortion that this country saw yesterday.

in the 1950s leading up to the 1960s. And I think for a lot of people, those who oppose this legislation, it is the same issue. You know, it is about the sanctity of life. I think there is a big, big crossover there. There are concerns about what people in the UK are calling the slippery slope. Could you explain that? Yeah, the slippery slope...

Really, it's an idea that this legislation is just the start of a process, that it will be expanded. Canada is the country most often cited by opponents of assisted dying as an example of that, a place where assisted dying has been extended and

and made available to more and more people since it was first brought in. Their legislation is called Medical Assistance in Dying. It's known by the acronym MAID, M-A-I-D. It was introduced in 2016 initially just for those people who are terminally ill. That was then amended later in 2021 and extended to those experiencing what they call unbearable suffering from an irreversible illness or disability.

And it's still due to become available to those with a mental illness in roughly three years' time, but there have been lots of delays to that.

The expansion of medical assistance and dying won't happen before the next federal election. The federal government announced earlier today it was hitting pause on expanding the program to include those suffering from mental illness. That was after a special committee of legislators said Canada's health system just isn't ready for that yet. But critics say that the law has widened as that's happened already.

more disabled and vulnerable people fear that they are being put at risk. And there's been a dramatic growth, a big growth in the number of people who are using that legislation. So four in 100 deaths in Canada are now medically assisted compared to only about one in 100 in Oregon in the United States. Dominic, isn't there also the issue that...

the terminally ill, people who are in terrible suffering, who are suffering from incurable diseases and in pain, there are loved ones close to such individuals who cannot bear the person they love so much to suffer so much and even

even though they know it's against the law, feel compelled to help them. Those in favour of this legislation say, look, it's just recognising something that's happening anyway. Yeah, I mean, I don't think anyone would argue that the law as it stands is a bit of a mess in the UK because we have a de facto moratorium on prosecutions of people who, for example, might help a relative go to Switzerland to go to a Dignitas clinic to end their life.

And there is also this argument that many people make that some people are choosing to end their lives early because

because they need to be able to travel to Switzerland. So they're making that choice earlier than they would otherwise do so. If they had this legislation, they could do it later in the comfort of their own home, surrounded by friends and family, that sort of thing. It's a devastating discussion, really, isn't it, Dominic? And this is particularly unpleasant to mention, but it is in the minds of lawmakers today.

Could there be an economic interest involved? And that would prevent this legislation being passed. An economic interest from the point of governments, for example, so lawmakers, because we know our societies are aging and an aging population is much more costly when it comes to healthcare provision or an economic interest from doctors. Could people shop around to private doctors? And might doctors give a yes and sign a piece of paper if they're getting paid?

That's one of the arguments that people use when they're against the legislation. They say there hasn't been enough time for this kind of detail to be gone through. They say there hasn't been an impact assessment carried out, particularly on the impact on the health service. So, for example, the health secretary, Wes Streeting, he argues that the palliative care system in the UK isn't good enough to support assisted dying. He says that the costs of implementing the necessary changes could lead to cuts in other NHS services.

I've made it clear that I'll be voting against the assisted dying bill this time. That's mainly because I don't think that palliative care, end of life care is where it needs to be to give people a real choice. I'm concerned about the risk of people being coerced into taking their lives sooner than they would have liked.

or feeling, even without pressure from their families, sometimes guilt-tripped, feeling like a burden. And I've had to weigh up all of those issues. However, proponents of the bill say if the bill gets passed on Friday, then the machinery of government will kick in and you then get things like a proper impact tax.

assessment. And they have built into the bill safeguards to stop that kind of shopping around like you were talking about. So for example, that's the role of the High Court judge who would have to review every single application. And I think some of those arguments are worth exploring. And if this legislation gets through on Friday, there will then be weeks and weeks of a committee of MPs will go through the legislation line by line,

If it doesn't, that is absolutely not the end of the issue. I think one of the really interesting things about the debate that has taken place in the UK over the last few months is it hasn't really been limited to left or right. Certainly outside of the United States, it doesn't seem to be an issue that is limited by party affiliation. Dominic, thank you. My pleasure.

And thanks so much to you for listening. If you want to get in touch, you can email us at theglobalstoryatbbc.com or send us a message or voice note on WhatsApp. Our number is plus 44 330 123 9480. And you can find all those details in our show notes. Wherever you're listening in the world, this has been The Global Story. Thanks for having us in your headphones. Goodbye.

I'm Crassi Twig, and on the documentary we zoom in on the backstory of the Syrian militant group that led a coalition of rebels to take control of Aleppo. Once an offshoot of Al-Qaeda, HDS rebranded itself in its desire to be seen as a credible governing body. To listen to this episode of The Global Jigsaw, where we look at the world through the lens of its media, search for the documentary wherever you get your BBC podcasts.